臺灣博碩士論文加值系統

研究目的
近年來醫學科技的發達與進步，各種先進的醫療儀器設備不斷的
推陳出新，而使得許多呼吸衰竭的病患得以延續生命，加上人口老化
與慢性病的盛行，需要長期依賴呼吸器而生存的病患，亦有逐年增加
的趨勢。在臨床使用呼吸器的個案中，約有20- 25%的病患在潛在的
問題解決之後，仍無法立即脫離呼吸器，而需長期使用呼吸器，甚至
有些個案根本無法脫離呼吸器，而成為呼吸器依賴者。
本研究的目的在於希望藉由回溯性的資料整理與統計後，藉以
瞭解影響呼吸器依賴病患呼吸器脫離之相關因子，探討此類病患醫療
資源使用情形及其相關影響因素，並追蹤病患該次住院於出院後一年
的存活情形。希望能藉此建立未來評估呼吸器依賴病患健康照護之可
能指標，以及提供健康照護機構擬定病人照護計畫之參考，對於成功
脫離機會較高的病患給予積極的訓練；而對於脫離機會較渺茫者，能
儘早轉至呼吸照護病房或居家使用呼吸器。以期能有效降低醫療資源
的耗費，且能達到較佳的醫療效果。
研究方法
本研究為回溯性之研究，主要是針對南部某醫學中心，於2006
年1月至2007年12月住進呼吸照護中心之病患為主要研究對象，共計
III
284位。以直線複迴歸分析、對數複迴歸分析與Cox成比例危害分析，
探討研究期間病患的人口學特質、使用呼吸器的主要原因、呼吸器脫
離相關指數、疾病嚴重度、是否有合併症、是否因脫離失敗再次使用
呼吸器、再次使用呼吸器的天數及相關血液生化值，對呼吸器依賴病
患呼吸器的脫離、死亡率、當次住院之醫療費用與住院天數的影響。
研究結果
研究結果顯示，研究期間病患平均年齡為72±15歲，男性病患152
例（53.5%）多於女性，以內科加護病房所轉入的病患居多（57.4%）；
使用呼吸器的主要原因以充血性心衰竭（CHF）最多（27.5%），病患
疾病嚴重度（APACHE II）平均為16.84±4.23、Charlson Comorbidity
Index（CCI，合併症指數）平均為1.95±1.61；有31.3%的病患有作氣
切，當次住院出院後一年內的死亡率為55.63%。
在線性複迴歸模式中，病患是否因脫離失敗而再次使用呼吸器
比較會成為呼吸器依賴患者（P＜0.001）；在影響醫療費用耗用的相
關因素中，以是否因呼吸器脫離失敗而再次使用呼吸器影響最大，其
次為是否有作氣切（P＜0.001）。
以Cox迴歸探討病患該次住院出院後的一年內與存活有關之主
要影響因子，結果顯示性別、有合併心臟系統疾病、血中尿素氮值、
APACHE II及因為充血性心衰竭而使用呼吸器皆是影響死亡與否之
IV
重要因子。
於影響住院天數相關因素的線性迴歸分析中，結果顯示病患是否
有氣切、合併症指數（CCI）、是否因呼吸器脫離失敗而再次使用呼吸
器及再次使用呼吸器的天數皆是影響病患住院天數之重要因子，在影
響住院天數相關因素中，以再次使用呼吸器的天數影響最大，其次為
是否因呼吸器脫離失敗而再次使用呼吸器。
結論與建議
本研究證實病患其是否作氣切、是否因呼吸器脫離失敗而再次使
用呼吸器、合併症指數及再次使用呼吸器的天數，是呼吸器依賴病患
其是否能成功脫離呼吸器及減少醫療資源耗用最具影響力之變項，因
此建議要為呼吸器依賴病患做呼吸器脫離之準備時，能給於足夠的相
關訓練且在疾病病程穩定控制後再進行，如此應可以降低病患死亡
率，提高病患呼吸器的脫離率，並進而減少病患住院天數，降低其醫
療資源之耗用。

Research Purposes
In recent years, with the development and progress of medical
technology, there are more and more advanced medical instruments and
equipment available, allowing many patients with respiratory failure to
survive. Moreover, with population ageing and the prevalence of chronic
diseases, the number of long-term ventilator-dependent patients has
gradually increased. Clinically, among patients who use ventilators to
maintain their life, around 20-25% of them cannot immediately wean
from the ventilator after their potential problems have been solved. And
among patients with long-term use of ventilators, some individuals even
cannot wean from the ventilator and eventually become
ventilator-dependent patients.
The purposes of this study are to understand the influencing factors
of ventilator weaning in ventilator-dependent patients, investigate the
utilization of medical resources and its relevant influencing factors for
these patients, and track to the survival rate of these patients within a year
after hospital discharge by collecting retrospective data and statistics. It is
hoped that this study can help construct evaluation indices for the health
care of ventilator-dependent patients and provide health care facilities
with references for planning the health care of patients, offering more
training to patients of higher weaning success rate, and transferring
patients of lower weaning success rate to respiratory care wards or
sending they home for receiving ventilation at home to effectively reduce
the cost of medical resources and achieve better medical effects.
Research methods
This study is a retrospective study and the research subjects were
mainly the patients hospitalized in the respiratory care center in certain
medical center in southern Taiwan from January, 2006 to December,
2007. A total of 284 patients were enrolled in this study. Statistical
methods such as multiple linear regression analysis, multiple logistic
regression analysis, and Cox proportion hazards analysis were used to
investigate the influences of demographic profiles of patients, main
reasons for using ventilators, relevant indices of ventilator weaning,
disease severity, the presence of complications, using ventilators again
due to weaning failure, the days of reusing ventilators, and relevant blood
biochemical values on the ventilator weaning, mortality, medical
expenditure, and the inpatient days of ventilator-dependent patients.
VI
Research results
The research results indicated that the average age of patients was
72±15 years and the number of male patients was 152 (53.5%), which
was more than female ones; most of the patients (57.4%) were transferred
from the internal intensive care unit; the main reason for using ventilators
was mostly (27.5%) congestive heart failure (CHF); the average disease
severity of patients (APACHE II) was 16.84±4.23; the average Charlson
Comorbidity Index (CCI) was 1.95±1.61; 31.3% patients had received
tracheostomy; the mortality of patients after hospital discharge within a
year was 55.63%.
The multiple linear regression model indicated that patients with
weaning failure and using ventilator again had a higher possibility to
become ventilator-dependent patients (P<0.001); among the relevant
influencing factors for medical expenditure, the most influential factor
was using ventilator again due to weaning failure, followed by receiving
tracheostomy (P<0.001).
The Cox regression analysis was used to investigate the main
influencing factors relevant to the survival rate of patients after hospital
discharge within a year. The results indicated that gender, presence of
cardiac complications, the value of blood urea nitrogen, APACHE II, and
using ventilator due to congestive heart failure were all important factors
that influenced the mortality of patients.
The results of linear regression analysis for analyzing the relevant
factors of inpatient days indicated that receiving tracheostomy, Charlson
Comorbidity Index (CCI), using ventilators again due to weaning failure,
and the days of reusing ventilators were all important factors which
influenced the inpatient days of patients. Among the influencing factors
of inpatient days, the most influential one was the days of reusing
ventilators, followed by using ventilators again due to weaning failure.
Conclusions and suggestions
The study showed that the receiving tracheostomy, using ventilators
again due to weaning failure, Charlson Comorbidity Index, and the days
of reusing ventilators were the most influential variables for determining
whether ventilator-dependent patients could successfully wean from
ventilators and reduce the cost of medical resources. Therefore, to reduce
the mortality of patients, increase the weaning success rate, decrease
inpatient days, and reduce the cost of medical resources, it is suggested
VII
that when preparing for weaning ventilator-dependent patients from
ventilators, it is necessary to provide patients with enough relevant
training and the weaning shall be conducted after patients’ condition is
steadily controlled.

目 錄
致謝……………………………………………………………………I
中文摘要………………………………………………………………II
英文摘要………………………………………………………………V
目錄…………………………………………………………………VIII
表目錄…………………………………………………………………IX
圖目錄…………………………………………………………………X
第一章 緒論……………………………………………………………1
第一節 研究背景、動機與流程…………………………………1
第二節 研究目的…………………………………………………4
第二章 文獻探討………………………………………………………5
第一節呼吸衰竭之定義…………………………………………5
第二節 使用呼吸器的適應症與合併症…………………………8
第三節 呼吸器依賴的影響因素…………………………………27
第四節 全民健康保險呼吸器依賴病患照護前瞻性支付試辦計畫
與相關研究結果……………………………………… 30
第五節 呼吸器依賴病患成本分析………………………………40
第三章 研究方法………………………………………………………44
第一節概念架構與研究假說……………………………………44
第二節 研究設計與研究樣本……………………………………48
第三節 研究對象與資料來源……………………………………50
第四節 研究變項與操作型定義…………………………………53
第五節統計方法…………………………………………………56
第四章 結果與分析……………………………………………………58
第一節研究樣本人口學特質描述………………………………58
第二節 呼吸器脫離與否、死亡與否、醫療費用、住院天數的
相關性分析………………………………………………61
第三節 影響呼吸器脫離與否、死亡與否、醫療費用、住院天
數的相關因素……………………………………………71
第五章 討論與結論……………………………………………………77
第一節呼吸器依賴病患呼吸器脫離的情形、死亡率及其影響
因子………………………………………………………77
第二節呼吸器依賴病患之醫療資源耗用及其影響因子………81
第三節呼吸器依賴病患之住院天數與其影響因子……………85
第四節研究限制及未來研究方向………………………………87
第五節結論和建議………………………………………………88
參考文獻……………………………………………………………… 91
中文文獻…………………………………………………………… 91
英文文獻…………………………………………………………… 93
IX
表目錄
表 3-1 各變項之操作型定義………………………………………55
表4-1 人口學特質………………………………………………… 60
表4-2 各自變項對脫離與否的相關性…………………………… 62
表4-3 各自變項對死亡與否的相關性…………………………… 65
表4-4 各自變項對醫療費用耗用情形…………………………… 68
表4-5 各自變項對住院天數的相關……………………………… 70
表4-6 影響脫離與否的相關因素………………………………… 71
表4-7 影響存活與否的相關因素………………………………… 72
表4-8 影響醫療費用的相關因素………………………………… 73
表4-9 影響住院天數的相關因素………………………………… 74
表4-10 脫離與否及死亡與否與費用及住院天數………………… 75
表4-11 醫療費用與脫離與否……………………………………… 76
表4-12 住院天數與脫離與否……………………………………… 76
表5-1 氣切時機之相關研究……………………………………… 83
X
圖目錄
圖 1-1 研究流程…………………………………………………… 3
圖2-1 整合性呼吸照護體系流程及給付方式…………………… 36
圖3-1 概念架構…………………………………………………… 45
圖 4-1 存活分析……………………………………………………. 64

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